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Evaluation of Preeclampsia at Term

2/1/2018 - Cynthie K. Anderson, MD, MPH

 

Mentor: Tony Ogburn, MD

Editor: Tiffany A. Moore Simas, MD, MPH, MEd

 

Gravidas at term (≥37 weeks) with new-onset hypertension or symptoms suggesting potential end organ effects such as headache, visual changes, or right upper quadrant or epigastric pain, should be evaluated for preeclampsia.  The evaluation aims to diagnose preeclampsia and identify severe features. Term preeclampsia requires hospital admission for management and delivery.

Preeclampsia diagnosis includes elevated blood pressures (SBP ≥140 or DBP ≥90) on two occasions separated by ≥4 hours. If severe hypertension is present (SBP ≥160 or DBP ≥110), the diagnosis can be confirmed after a shortened interval to expedite initiation of anti-hypertensive therapy. Severe BP elevation raises risk for hemorrhagic stroke, placental abruption, and death. Optimal BP measurement is taken with the patient seated comfortably, legs uncrossed, relaxed, not talking, and arm supported so the cuff is at the level of the heart.  In addition to BP criteria, diagnosis requires proteinuria or one of the following:  thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms.  Proteinuria is defined as either ≥300 mg/24-hour urine collection, the equivalent amount extrapolated from a timed collection, or spot urine protein/creatinine ratio ≥0.3. Urine dipstick readings are discouraged, but dipstick ≥1+ may be used if quantitative methods are not available.  Thrombocytopenia is defined as platelets <100,000/microliter. Renal insufficiency is defined as creatinine >1.1 mg/dL or a doubling from baseline in the absence of other renal disease. Impaired liver function is diagnosed when transaminases are greater than or equal to twice normal. Other blood tests have been suggested, such as lactate dehydrogenase or uric acid, but are not required or diagnostic.

Rapid identification of severe features is important so magnesium sulfate can be initiated for seizure prevention.  Severe features include severe hypertension, new-onset cerebral or visual disturbances, pulmonary edema, thrombocytopenia, impaired liver function, and progressive renal insufficiency. When severe features are present, “preeclampsia with severe features” is the accepted terminology. When severe features are not present, but women otherwise meet criteria for preeclampsia, “preeclampsia without severe features” is the correct terminology. Since preeclampsia is a serious and potentially life-threatening disorder, the term “mild” is misleading and no longer recommended.

Fetal well-being should be ascertained by antenatal testing (NST with AFI or BPP).  

Initial evaluation thus includes:

  1. Blood pressure
  2. Review of symptoms
  3. Laboratory tests for proteinuria, CBC with platelets, creatinine, AST, and ALT
  4. Antenatal testing

Initial management includes: (1) delivery with mode determined by fetal presentation, and usual maternal/fetal obstetric considerations, (2) anti-hypertension therapy for severe hypertension, and (3) magnesium for seizure prophylaxis with severe features.  BP monitoring should continue for at least 72 hours postpartum, and again 7-10 days postpartum, or earlier if symptoms are present.  Blood pressure monitoring should continue until the patient is confirmed to be normotensive or the diagnosis of chronic hypertension is confirmed.

 

Further Reading:

Roberts JM, August PA, Bakris G, et al. American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in Pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013 Nov;122(5):1122-31. doi: 10.1097/01.AOG.0000437382.03963.88.

Initial approval 11/2017.  Published 2/1/18

 

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